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Abstract
Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.
A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).
118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.
Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.
- Consensus
- Female
- Pelvic floor
- Running
- Women in sport
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Running is associated with high rates of pain and injury, both in the general population and following childbirth.
High-quality evidence on designing a return-to-running training programme is limited.
WHAT THIS STUDY ADDS
Some period of recovery (ie, relative rest) is recommended after childbirth; the length of the recovery period will be specific to each individual’s pregnancy, birth and postpartum experience.
A gradual exercise progression is recommended to facilitate cardiorespiratory and muscular reconditioning prior to initiating running.
The progression or regression of exercise training should be determined by a number of biopsychosocial factors, including sleep quality and quantity, mental health status, lactation status, social support, socioeconomic status and musculoskeletal dysfunction (including pain and pelvic health symptoms).
Strengthening exercises for trunk and lower extremity muscles are important prior to and after returning to running.
The majority of experienced professionals in postpartum running treat clients who self-pay for services, highlighting cost as a potential barrier for some postpartum runners to seek professional guidance.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
A high incidence of injury and/or pain in postpartum runners (elite and recreational) highlights the need for a gradual progression of training.
Due to limited evidence and athlete calls for improved guidance on postpartum training, further research is needed on postpartum runners to determine best practices for designing and progressing a training programme.
Maternity leave protections are necessary to allow sufficient time to implement a gradual progression of exercise and training.
Introduction
The last century has seen a change in our view of what athletic females can or should do. In 1926, Violet Piercy was the first female in modern times to run in a marathon recognised by the International Association of Athletics Federations. It would be decades before female runners would become commonplace, and 2018 was the first year that females made up more than half of all runners.1 In the last decade, Allyson Felix, the most decorated athlete in World Athletics history, smashed societal norms by returning to elite sport as one of the top runners in the world after experiencing an emergency preterm caesarean delivery due to pre-eclampsia.2 3 While she has served as a role model for future mother-athletes, some runners—whether elite or recreational—report facing several barriers to returning to running after childbirth.4–6 Felix, along with other professional runners like Alysia Montano and Kara Goucher, has also reported facing significant pay cuts from sponsors while navigating pregnancy and the recovery from childbirth, which puts undue pressure on athletes to rapidly return to pre-pregnancy performance.7
At the elite level, up to 50% of postpartum runners report injuries that delayed training, running or competition,8 while 33%–84% of recreational postpartum runners report running-related pain.9 10 While running-related injuries (RRIs) and pain are common in the general running population,11 the prevalence of pain and injury in postpartum runners may be due to a lack of evidence-informed guidance provided by healthcare, clinical, fitness and rehabilitation professionals on how to return to running safely.4–6 Some athletes report anxiety regarding injury susceptibility after childbirth, which can also act as a barrier to returning to sport and athletic performance.4 5 Given the high rates of pain and injury among postpartum runners, along with the increased risk of pelvic health symptoms (eg, incontinence and pelvic organ prolapse (POP)), guidance on how to return to running after childbirth is essential.8–10 12 13
It is increasingly recognised that rehabilitation following pregnancy and childbirth is needed to optimise return to running.14–18 Following major injuries or surgeries, postoperative protocols or rehabilitation guidelines provide individuals with phase-specific exercises.19 20 These guidelines are based on tissue healing, the individual’s symptoms, psychological readiness and clearly defined goals that indicate an individual’s ability to safely progress to the next stage, eventually culminating in a full return to the desired level of exercise or sports participation.19 20 Pregnancy and childbirth can result in several biopsychosocial changes (eg, incontinence, depression, muscular weakness, lack of social support, etc) that may influence physical activity (PA) and/or exercise participation and performance.21–25 Consequently, some postpartum females may benefit from directed, evidence-informed guidance on how to start and progress in PA and exercise, as well as access to health and fitness professionals who can identify specific areas of impairment and tailor a return-to-exercise programme. In the last 5 years, postpartum return-to-running guidelines and frameworks have been suggested to support a safe return to running.14–18 26 However, it is unclear what specific parameters are used by exercise and clinical professionals for the progression of PA and exercise to running postpartum, how those parameters align with best practice or what barriers postpartum runners face when trying to access this expertise. As consensus and expert opinion recommendations on how to determine postpartum run-readiness have been described elsewhere,27 this study sought to establish an international consensus on key topics related to designing a postpartum training plan to facilitate return to running (ie, training plan design and key muscle groups to strengthen) by surveying experienced clinical and exercise professionals in postpartum running. Study participants were also asked to identify current practice factors that may act as barriers to postpartum females accessing professional return-to-running guidance (ie, referral sources and payment sources) and to identify where they obtain information that guides their professional practice.
Methods
A three-round Delphi survey design was used.28–32 The study was approved by the Elon University Institutional Review Board. Methods are outlined in detail in a previous manuscript.27 In summary, the authors (all of whom are research and/or clinical experts in perinatal health) developed an initial survey of open-ended questions regarding the return to running after childbirth. This initial survey was piloted by experts in the field who are no longer working with postpartum runners. The survey was edited based on feedback from the pilot participants and used for Round I.
Participants (respondent group)
Inclusion criteria are described in a previous manuscript.27 Briefly, all participants had to be health, exercise or fitness professionals who worked with postpartum runners. A minimum of 5 years of professional experience with postpartum runners was used as the threshold to be considered ‘experienced clinical and exercise professionals’ unless their caseload was reported to be ≥50% postpartum runners, in which case the 5-year minimum was waived. Recruitment was conducted through a purposeful snowball sampling method. All possible participants completed a recruitment survey, which was used to determine if the inclusion criteria were met.
Procedure
An overview of the study procedure is provided in figure 1. Participants received an email through Qualtrics (Seattle, WA, USA) with a personalised link to each round of the survey, which prevented each participant from completing the survey more than once while also allowing respondents to complete the survey in multiple attempts. Respondents were not notified of who else was participating in the study; thus, responses were anonymous. Written informed consent was obtained on the first page of each survey round. Consensus was defined a priori as 75% agreement.33 Round I was distributed to all interested participants who met inclusion criteria, while Rounds II and III were only distributed to those participants who completed the Round I survey.
Conducting and reporting Delphi studies flowchart of study development, piloting, recruitment and survey distribution.
Round I survey
The first round consisted of demographic questions, referral patterns and how clinical and exercise professionals are compensated for the services they provide to postpartum runners, as well as four open-ended questions about return-to-running programme development (exercises, running progression, amount of mileage initially and milestones for advancement). Participants were also asked about sources of information that inform their clinical decision-making.
Round II survey
Four authors (SMC, RED, SD and MHD) with experience in consensus statements and/or mixed-methods research coded the responses from Round I to identify common themes. These themes were used to develop the Round II survey, which consisted of statements and a four-point Likert scale for respondents to indicate their level of agreement or disagreement with each statement. Some gaps in knowledge were also identified during Round I coding, and additional free-text questions were developed and included in Round II to obtain additional information, such as specific starting points for a mileage-based or time-based run training plan.
Round III survey
For Round III, the Likert-scale questions from Round II were presented again with graphs indicating participant responses (percentages of respondents who strongly agreed, agreed, disagreed and strongly disagreed) from Round II, and respondents were again asked to rate their level of agreement using a Likert scale. The free-text questions from Round II were thematically coded, and themes were presented as statements with a Likert scale to indicate the level of agreement when there were any gaps in the knowledge. As these items provided specific parameters used by the respondents for previously established themes (time-based vs mileage-based progression), these items only went through one round of voting.
Evidence review
All authors participated in the review of evidence, searching for articles related to exercise, rehabilitation, running and/or sport in the postpartum period, after childbirth or after pregnancy. Evidence review was used to inform the creation of Round I survey questions and to determine if the results of the clinical and exercise professional consensus were in line with current research evidence, thus allowing the authors to make final recommendations on each topic. The level of evidence is provided for the literature summary after each consensus section.34 The level of evidence of each study cited in the current evidence sections is provided in online supplemental file 1.
Supplemental material
Author recommendations
The authors discussed the Delphi data and current evidence, leading to the development of recommendations for each section. A survey consisting of the recommendations created from group discussion and free-text options to indicate dissenting opinions was then sent to all authors. A second survey with all the author-suggested recommendations for each section was then sent out. Unanimous agreement was obtained after two rounds on all recommendations except one, which had one dissenting opinion.
Equity, diversity and inclusion statement
The author group consists of 12 women, primarily white and a woman of colour, from five different countries. Clinical and exercise professionals (respondent group) were included based on the number of years working with postpartum runners, and thus, junior, mid-career and senior-level practitioners from a variety of professional backgrounds were included. Only two men participated in the Delphi survey as respondents. In discussing the generalisability of our results and limitations in our findings, we recognise that these results may exclude professionals of a low socioeconomic status, where advanced education is unavailable, or from marginalised communities as perinatal care is not part of basic training in many professions.
Results
Respondent group
222 participants met the inclusion criteria and were sent a link for Round I. 118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Demographics for the respondents are presented in table 1.
Respondent group demographics
Referral sources and payment
Referral sources and methods of payment are presented in tables 2 and 3. The top three sources referring postpartum runners to clinical and exercise professionals were: (1) self-referral, (2) primary care providers and (3) birth providers. In Round I, 42% of respondents indicated that they exclusively work with self-pay postpartum running clients (ie, care is not covered by insurance or a universal healthcare system) and 78% reported that at least part of their caseload was self-pay.
Respondent group reported sources of referral of postpartum runners
Experienced professional report payment sources
Sources of information for clinical decision-making
In Round I, participants were asked to identify specific sources used to inform their clinical decision-making while designing postpartum return-to-running training programmes. Five themes were identified (table 4), with non-peer-reviewed expert opinion being the most common source.
Experienced professional reported sources of information to inform clinical decision-making when working with postpartum runners
Consensus on designing a postpartum return-to-running training programme
Training plan design
Consensus
The consensus was reached (92.9%) that how the return-to-running plan is implemented (ie, dosing of exercise) is more important than when a runner returns to running after childbirth (ie, weeks postpartum). Respondents also agreed (97.7%) that it is better to be conservative than to progress too fast too soon. The consensus was reached that the run-training programme should incorporate a progression of walk-run intervals (98.8%), cross-training (95.3%), strength training (100%) and a rest day between runs (75.3%). Consensus was also reached (98.8%) that the amount of running prescribed in the initial stages of run training is dependent on the runner’s running history, including time since their last run and how far they were running at that time. Additionally, consensus was reached regarding the optimal starting point for a return-to-running programme from a time perspective, but not from a minimum distance perspective (table 5).
Experienced professional consensus on mileage versus time considerations for postpartum run-training programme
Current evidence
All runners will experience some deconditioning during recovery following birth and will require reconditioning prior to resuming running.15 16 35 The degree of deconditioning will influence the duration of the rehabilitation phase.15 16 35 A gradual return to baseline (pre-pregnancy) fitness is encouraged,35 and experienced clinical and exercise professional consensus recommends that an individual first be able to walk 30 min without pelvic health or other musculoskeletal symptoms before being assessed for run readiness.27 While some postpartum females can resume symptom-free PAs and exercise prior to 6 weeks postpartum,36 37 others may be more susceptible to injury.8 24 Although the underlying mechanisms are unclear, recent literature has reported bone stress injuries (BSIs) in lactating elite athletes (~3% of elite athletes; 43% of BSIs were sacral stress fractures), some of which have occurred during non-impact exercises, such as cross-country skiing.8 24 In addition, several case studies have reported sacral stress fractures in sedentary postpartum females with and without normal bone mineral density.38 39 Although BSIs after childbirth are relatively rare, the elevated risk of sacral stress fractures compared with nulligravid females highlights the importance of the gradual progression of low-impact aerobic activities to ensure an appropriate progression of load and to monitor for signs and symptoms of BSI before initiating high-impact activities. Regarding rest between run days, no literature exists in the postpartum population. In the general running population, two expert opinion papers have suggested 1 day of rest between run days for the first 2 weeks of a run-training progression following a return to running after a stress fracture,40 41 and one study on elite endurance athletes showed that less than two rest days per week during training was associated with a 5.2-fold increased risk of overuse injury42 (overall level III evidence with minimal level I evidence).
To our knowledge, there is no evidence to support a mileage-based versus time-based approach when designing a run training programme for the general population. A recent expert opinion suggested a mileage-based approach for postpartum return to running in an effort to control total load accumulation and load tolerance,14 as rapid mileage progression (>30%) has been shown to cause an increase in injury risk.43 44 This expert opinion also recommended that running speed be held constant while mileage progresses and suggested the use of RPE to avoid drastic increases in intensity while using a mileage-based approach14 (overall level V evidence).
Recommendations (12/12 authors assent)
The length of the recovery period after childbirth is person-specific and should be based on the individual’s symptom and risk-factor profiles (eg, physiological recovery, tissue healing, training history, psychosocial factors, etc). Once readiness-to-run has been established, the initiation of run training should begin slowly with a walk-run protocol to assess symptom provocation. Cross-training can be used to optimise cardiorespiratory and muscular fitness prior to and after initiating running. Although BSI is a relatively rare occurrence, particularly in non-elite athletes, runners (and the professionals working with them) should be vigilant for signs and symptoms of BSI. Due to a lack of evidence, no recommendation can be made regarding the amount of rest or recovery between runs (ie, the spacing of run days). No recommendation can be made at this time regarding the use of a mileage-based or time-based run training plan.
Progressions and regressions based on biopsychosocial factors
Consensus
There was unanimous agreement that biopsychosocial factors (eg, sleep, fatigue, pain, social support, infant needs, energy availability, lactation, etc) should be considered when adapting training (progression vs regression) and that the progression of the run training programme should be specific to each runner’s goals. There was no agreement on how run training programmes should progress (eg, distance vs time), but agreement was reached (89%) for educating runners on the need to cease running portions of walk-run programmes if pelvic health symptoms arise (table 6).
Experienced professional consensus on progression of the postpartum run-training programme
Current evidence
When considering biopsychosocial factors, sleep has been identified as an important predictor of athletic performance and injury.45 Sleep is often disrupted while caring for an infant,46 with poor sleep and fatigue having been identified as barriers to exercise participation in postpartum females.6 47 Sleeping less than 6.8 hours/night and a Postnatal Accumulated Fatigue Scale (a validated questionnaire that assesses physical, emotional and cognitive fatigue, with a maximum score of 39 indicating severe fatigue in all three subsections)48 score ≥19 were identified as risk factors for postpartum running-related pain,9 which is experienced by 33%–84% of postpartum runners.9 10 However, engaging in regular PA is associated with improved sleep quality and duration, as well as tiredness and daytime function during the perinatal period.49–51 Thus, encouraging some level of PA postpartum may have a beneficial impact on sleep, but sleep deprivation may also prevent participation in impact exercises like running and/or increase the risk of running-related pain in postpartum runners (overall level II evidence).
Lack of physical and emotional support from family or healthcare professionals is consistently cited as a key barrier to exercise in the general postpartum population.23 47 52 Elite athletes (including, but not limited to, runners) have also expressed a lack of social support—including childcare and sports organisations and policymakers—as well as negative public opinion as challenges to returning to training after childbirth5 53 (overall level I evidence, some level II evidence).
Lack of social support and increased stress are two of many established factors that contribute to depression and anxiety postpartum.54 One in seven postpartum females worldwide is affected by depression or anxiety, with even greater prevalence (~33%) in low-income and middle-income countries.22 55 Maternal depression and anxiety can negatively impact mother–child bonding and child development.56 PA can be beneficial for preventing and ameliorating postpartum depression and depressive symptoms.57 The use of validated measures to screen for postnatal depression and well-being issues when returning to activity has been recommended to allow for targeted, appropriate support16 (level I to level V evidence).
The consensus from the Delphi respondents also identified two important biological factors to consider when adapting the postpartum training plan: (1) lactation and (2) the risk of relative energy deficiency in sports (REDs). Energy requirements increase after childbirth for lactating females and vary based on the timeframe postpartum.58 A multicentre study of lactating females found that overall energy intake and intake of several key vitamins and minerals were below the recommended amounts.59 Problematic low energy availability (LEA) and REDs in female athletes are associated with a number of detrimental conditions, such as urinary incontinence (UI),60 61 BSI, cardiovascular dysfunction and endocrine dysfunction, all of which affect exercise participation and performance.62–64 Energy balance is a difficult construct to assess in a lactating athlete65 as many lactating females experience a prolonged absence of the menstrual cycle,66 a commonly used marker of energy status in non-lactating athletes.63–65 67 68 In healthy lactating females (ie, in the absence of chronic LEA), there is sufficient evidence to show that PA and exercise are compatible with breastfeeding. Low-intensity to moderate-intensity aerobic activities do not alter levels of cortisol or lactic acid in breastmilk and will not impair the volume of breastmilk as long as hydration and nutrition intake are adequate.69 70 Maximal or very high-intensity activities have been shown to influence breastmilk composition,71 but further high-quality research is needed in this area (overall level II evidence).
There is no evidence to date that has assessed an ideal magnitude of change in running volume in postpartum runners when progressing in run training. In the general running population, sudden increases in mileage or intensity have been hypothesised as risk factors for RRIs. In novice runners, a running mileage progression of ≥30% compared with ≤10% in a span of 2 weeks was associated with a 59% greater volume of injury.43 44 In healthy runners training for a half-marathon, a progression of running distance by <20% per week was associated with a 22.6% decreased risk of developing an RRI.72 Recent changes in velocity, distance and/or running frequency have also been shown to increase the risk of RRI.73 In addition, the runner’s training history may also influence RRI risk; novice postpartum runners have increased odds of developing running-related pain.9 In the general population of novice runners, the use of structured run progressions (such as ‘Couch to 5K’) has been associated with decreased injury risk compared with self-progressing.74 When considering what component of the training plan to progress first, general exercise physiology evidence recommends increasing the duration of exercise prior to increasing intensity for safe progression of cardiorespiratory fitness and decreased risk of injury,75 which is also supported by a narrative evidence review on postpartum females engaging in elite sport and physically demanding jobs.76 Injury risk associated with increasing running volume has been shown to be similar to increasing running intensity, but in recreational runners with a degree of conditioning already present43 (overall level II evidence).
There is minimal long-term evidence of pelvic floor symptoms in postpartum runners,21 and no studies have been done to compare long-term pelvic floor function in runners who stopped the run-portion of a run-walk protocol due to the presence or exacerbation of symptoms to those who completed the run-portion of a run-walk protocol despite the presence or exacerbation of symptoms. That is, there is no evidence to say that terminating running due to pelvic health symptoms is protective of pelvic floor muscle (PFM) function or that continuing to run despite symptoms is detrimental to PFM function. It is known, however, that pelvic health issues are common in nulligravid female athletes (including, but not limited to, runners) and in the general postpartum population.13 21 35 61 77–89 Two of the three primary reasons that postpartum females report not returning to running are incontinence and pelvic organ prolapse symptoms.6 Returning to running was also associated with increased odds of UI compared with females who ran prior to or during pregnancy but did not return to running after childbirth10 (overall level II evidence).
To our knowledge, no evidence exists on muscle flexibility and functional mobility in postpartum runners. There is very low-quality evidence addressing the influence of muscle flexibility and range of motion on RRI in the general running population, with no clear associations identified regarding RRI and lower extremity range of motion or alignment.90 A recent Delphi study reported that clinicians working with postpartum runners identified impaired flexibility in the hip flexors, limited lumbar extension, ‘dynamic knee valgus, increased lumbar lordosis, overpronation and thoracic kyphosis’ in postpartum runners with running-related pain.13 However, the literature review did not support the Delphi consensus in that study13 (level I and level V evidence).
Recommendations (12/12 authors assent)
When determining whether to progress or regress training, several biopsychosocial factors (including sleep, mental health, lactation, energy availability, pelvic health, musculoskeletal symptoms, etc) should be monitored and training should be adjusted accordingly (ie, decrease running volume if symptoms arise or baseline symptoms are exacerbated; running volume can be progressed if symptoms are not present or existing symptoms do not worsen). When progressing run-training, only one variable should be changed at a time, and overall running volume should be progressed gradually, avoiding drastic increases in volume, to minimise injury risk. General principles of exercise prescription recommend that the duration (mileage or time) of exercise be progressed before intensity (speed).
Key muscle groups to target with exercise before and during run-training
Consensus
Several trunk (eg, PFMs and abdominal muscles) and lower extremity (eg, hip abductors and hamstrings) muscle groups reached consensus as key for exercise training while preparing for a return to running and throughout run training (table 7). The consensus was reached in both rounds that all postpartum runners should have a full musculoskeletal assessment and areas of impairment should be targeted with exercise (95.3%) and that specific muscle groups are less important than overall movement patterns (87.1%).
Experienced professional consensus on muscle groups to target with exercise before and during run training
Current evidence
Very little evidence exists comparing postpartum pelvic floor outcomes in active and athletic females and sedentary females. In the general postpartum population, there is evidence that several metrics of PFM function—such as ability to volitionally contract the PFMs, vaginal resting pressure (VRP), maximal PFM strength, PFM endurance, measurements of levator hiatus, etc—are commonly impaired, particularly following vaginal or instrumented vaginal birth.78 84 85 In addition, continent females have stronger and less fatigable PFMs than incontinent females.78 Up to 61% of females experience an episiotomy and up to 57% sustain perineal tearing during vaginal birth.91 Although all degrees of perineal trauma increase the risk for pelvic floor dysfunction (PFD), females who sustain third-degree or fourth-degree obstetric anal sphincter injuries (OASIS) during childbirth are at a higher risk of experiencing symptoms such as incontinence, pelvic pain, sexual dysfunction or prolapse.92 Only 30% of primiparous females with OASIS and 40% of primiparous females with no, or first-degree, perineal tears returned to normal urinary and colorectal function by 6 months postpartum.92 Forceps-assisted vaginal delivery increases the odds of PFD 5–10 years after first delivery.91 Females with PFM defects (such as avulsion) have been shown to have 47% lower strength and endurance, with no difference in VRP, compared with postpartum females without PFM defects.79 Most females with major defects can contract the PFM correctly, which implies that PFM training (PFMT) might be a worthwhile intervention in this population.79 Again, it is important to note that the majority of studies in this area have not been conducted on female athletes, and research on these topics in athletic females is necessary to determine if female athletes present similarly. A systematic review and meta-analysis of elite athletes showed no association between athlete status before or during pregnancy and the self-reported incidence of urinary and faecal incontinence after childbirth24 (overall level II evidence, with some level I).
It is important to note that postpartum PFD may be prevented by PFMT during pregnancy. A Cochrane review by Woodley et al (2020)93 found that there was a 22% reduced risk of UI in late pregnancy and the ‘mid-postnatal period’ in those who did PFMT during pregnancy. In randomised control trials (RCTs) of pregnant continent females (primary prevention) who exercise, those training the PFM were 62% less likely to experience UI in late pregnancy and had 29% less risk of UI at 3–6 months postpartum.93 There was insufficient evidence for an effect >12 months postpartum.93 As many females (45%) do not contract their PFMs correctly (ie, demonstrate compensatory muscle contractions, such as the gluteal muscles or abdominal muscles, instead of contracting the PFMs), when possible, professional assessment of PFM function and guidance of PFMT is ideal.85 Further studies are needed to assess the effect of PFMT on faecal incontinence and POP in the peripartum period (level I evidence).
Impairments in abdominal muscle function have also been reported in postpartum females. Strength and fatigability of the trunk flexor muscles, as well as fatigability of the lumbopelvic stabilising muscles, have been shown to be impaired in a mixed sample of postpartum females (ie, runners and non-runners) up to 6 months after childbirth compared with nulligravid females.25 94 Females with diastasis recti abdominis (DRA) demonstrate impaired trunk rotation strength compared with females without DRA at 1 year postpartum.95 A systematic review also highlighted the negative impact of DRA on physical functioning.96 Additionally, some females deliver via caesarean section, which warrants appropriate consideration of tissue healing and functional recovery.97 However, to date, there are no validated tools for determining such recovery97 (level I to level II evidence).
While general muscle strength has not been identified as a risk factor for RRI in the general population,90 98 it has been hypothesised that pregnancy may affect biomechanics.99 In initial small sample investigations, postpartum runners have weaker hip muscles than nulliparous controls.100 A Delphi study that investigated impairments in postpartum runners with running-related pain indicated that abdominal, hip and pelvic floor weakness were all impairments contributing to pain in postpartum runners13 (level II to level III evidence).
Recommendation (11/12 authors assent)
A return-to-running programme should include strengthening exercises in conjunction with a return-to-running plan. Postpartum runners with pelvic health symptoms should receive a specific PFMT. From a prevention standpoint, it is ideal to begin PFMT during pregnancy, further emphasising the need for a multidisciplinary perinatal care model. Considering the current evidence regarding PFM function in the general postpartum population, as well as the lack of evidence regarding PFM tissue healing in multiparous females and in athletic females, it is recommended that pelvic health symptoms be monitored throughout training and not just in the initial return-to-running phase. There is also sufficient rationale to support the evaluation and strengthening (when necessary) of abdominal muscles after pregnancy and childbirth. As research in postpartum running cohorts is limited but has identified hip weakness in postpartum runners, it is also suggested to evaluate the postpartum runner for weakness in the lower extremity muscles, particularly hip muscles.
Dissenting opinion (1/12 authors)
One author disagreed with the recommendation of evaluating for weakness of the lower extremity muscles due to a lack of evidence.
Discussion
The results of an international Delphi consensus survey of experienced clinical and exercise professionals on the development of a return-to-running exercise plan after childbirth have been contextualised by current scientific literature and refined by an international panel of researchers and clinical experts in perinatal exercise and rehabilitation. The recommendations provide an initial framework for clinical and exercise professionals to facilitate a postpartum-specific return-to-running plan (figure 2).
Infographic summarising the recommendations for designing a postpartum return-to-running training plan.
Limitations
Limitations of this study include the relative lack of research evidence in postpartum runners, resulting in the need to extrapolate findings from the general running population and the general postpartum population. In addition, a narrative evidence review was performed instead of a systematic review, as our goal was to see what is currently being done in the field, which would make an a priori systematic review impossible. Because we took our search terms and topics for the subsequent comparison with current literature from the Delphi responses, we chose to do a narrative evidence review that would allow us to thoroughly search all of the topics indicated by the Delphi respondents. Respondents were also predominantly white, female physiotherapists, which may bias the consensus survey results. However, this sample does include a broader multidisciplinary voice than previous expert opinions on this topic. In addition, the author group, which came to a consensus on the recommendations, is also composed of individuals from various areas of expertise. Finally, as these recommendations have not been tested in postpartum runners, future research validating this approach is warranted.
Clinical implications
While some runners are able to return to running after childbirth without major issues, the lack of evidence on postpartum running presents a barrier to both symptomatic and at-risk postpartum females who wish to run and to healthcare providers who are guiding them. Several expert opinion frameworks on the return to running have been proposed by small author groups.14–18 26 101 However, this consensus statement provides recommendations on the development of a postpartum training programme informed by a large, multidisciplinary, international group of experienced professionals and current research evidence. Widespread distribution of such recommendations may help to minimise barriers to returning to running postpartum and provide health and exercise professionals with more detailed, evidence-informed recommendations to apply to runners in their care.
As previously mentioned, many postpartum runners experience pain and/or pelvic health symptoms that may require further evaluation and treatment to facilitate continued engagement in PA and exercise.6 9 10 12 13 This Delphi survey identified that most clinical and exercise professionals working with postpartum runners primarily see self-paying clients who are self-referred, which highlights two key barriers to postpartum exercise: cost and access. These barriers are not novel findings—a recent systematic review identified financial concerns and healthcare provider knowledge gaps as barriers to postpartum females pursuing a healthy lifestyle (encompassing both nutrition and PA and exercise).23 Healthcare providers have also acknowledged that financial issues (primarily insurance coverage) and lack of healthcare access are barriers to postpartum females receiving appropriate postpartum care (not specific to exercise), particularly in regard to low-income postpartum females.102
Education needs to be provided to perinatal females regarding the resources available for PA and exercise engagement. Pelvic floor education is especially needed, as ~26% of postpartum females have no knowledge of the pelvic floor.85 An international survey of postpartum runners indicated that 62% of runners prefer to receive return-to-running education via websites and physiotherapists; only 41% preferred to receive return-to-running information from their general practitioner.103 As such, it is also necessary to educate birth providers and primary care practitioners on the importance of referring perinatal runners to rehabilitation and fitness professionals with expertise in perinatal exercise, running and pelvic health. There is also a need to increase the overall accessibility of perinatal rehabilitation and fitness services, both by increasing the number of educated professionals in these fields and by decreasing financial barriers to obtaining these services. Access to these professionals is especially crucial for elite athletes, and sport policy organisations should be educated on the importance of incorporating a multidisciplinary team in postpartum training in order to promote gender equity in sports. The need for a multidisciplinary team is further supported by the importance of monitoring biopsychosocial factors in perinatal care and by literature regarding the management of female athletes.14–18 104 105 Barriers to PA and exercise can negatively impact both maternal and child well-being56; thus, it is crucial to keep the runner running if this is their preferred exercise.
Research implications
The postpartum period is notoriously understudied. The dearth of knowledge regarding general postpartum exercise and PA, and the return to running specifically, leaves both patients and professionals with little to no evidence-informed guidance. There is a significant need to establish return-to-run protocols for postpartum runners of all experience levels via high-quality research studies to determine the incidence of injury. This consensus statement provides recommendations for programme design that should be tested for efficacy. There is also a need for research examining whether the inclusion of rehabilitation and fitness professionals throughout the continuum of perinatal care influences postpartum return-to-running timelines, the incidence of injury or pelvic health symptoms, and the percentage of runners that can continue running during pregnancy and return after childbirth. In addition, research is needed regarding clinical assessments for postpartum females, including screening tools for REDs in lactating amenorrheic females.65
Unfortunately, clinical and exercise professionals in this study indicated that most of their clinical decision-making on postpartum running is based on non-peer-reviewed opinion, with research being listed as the fourth of five sources of information. In addition, health professionals consistently report that they are not trained or up-to-date with best practice recommendations to guide perinatal PA.23 106 107 This highlights not only the critical need for further high-quality research in postpartum exercise and running but also the need to make research more accessible to the professionals in the field and the need for clinical leaders in the field to be up-to-date with best practice recommendations. Increasing open access to research may be the key to improved dissemination among professionals and the general public. For example, the first return-to-run postpartum guidance by Goom and colleagues,26 which was released on the author’s website and promoted on social media, led to subsequent research6 10 103 and their associated British Journal of Sports Medicine blog,108 which has over 69 000 views, highlighting the impact open access dissemination has had in this field. However, costs for publishing research findings in open-access formats are often burdensome for researchers, especially in a field where research funding can be difficult to obtain.15
Sport policy implications
The need for policy and contract protections for pregnant and postpartum athletes has received significant attention in recent years.4 5 53 While there is evidence to support that a return to PA and exercise can safely happen early in the postpartum period for some females,36 37 109 there is also evidence of injury risk and pelvic health symptoms in athletes following childbirth.9 10 21 24 35 As such, the highly individualised nature of pregnancy, childbirth and postpartum recovery provides a strong rationale for supporting protected recovery time for postpartum female athletes. Evidence on pelvic health symptoms, running-related pain, RRIs and BSIs in postpartum athletic females suggests the rate of training progression may be more closely associated with injury risk than when PA and exercise are first initiated in the postpartum period.8–10 24 This further supports the need for protected leave to allow gradual return-to-exercise and gradual progression of exercise to minimise injury risk. Furthermore, elite athletes have reported that a more generous time frame for return to sport would have lessened the challenges they faced when attempting to return to competition.5 Elite athletes have also admitted to a more accelerated progression of exercise due to pressure from sponsoring agencies and/or coaches to return to top performance within such a short period of time.5 In addition to physical recovery, there are many other reasons to support protected maternity leave policies, not only for athletes but for all postpartum females. These include, but are not limited to, promoting parent–child bonding, lactation struggles, mental health concerns, sleep quality issues associated with the postpartum period and time constraints for seeking out professional care for perinatal issues. Sport policymakers and agencies that sponsor elite athletes have an obligation to promote the health and well-being of postpartum athletes by acknowledging appropriate timelines for initiation and safe progression of exercise in the context of postpartum recovery and providing funding and access to a multidisciplinary healthcare team.
Conclusion
Research and consensus from clinical and exercise professionals support the recommendation that PA and exercise should be initiated at a low level (ie, low-impact and low-moderate intensity) after childbirth and gradually progress, while consistently monitoring for the following: (1) pelvic health symptoms, (2) musculoskeletal pain, (3) sleep, (4) mental health concerns (including, but not limited to, anxiety, depression and maternal–infant bonding) and (5) energy availability. There is a need for evidence-informed return-to-run guidance to be freely and easily accessible to the public so that postpartum females can be informed and empowered to carry out a basic self-screen if necessary due to a lack of available and affordable local healthcare providers. Furthermore, there is an urgent need to improve interest in and accessibility of evidence-based courses and/or literature to ensure that clinicians and fitness professionals are up-to-date with current best practices. There is also a critical need to support protected parental leave to allow for recovery and the safe, gradual progression of PA and exercise, as well as improved social support for postpartum females. Further research is needed in all aspects of postpartum exercise, with a concurrent need to increase the available research funding for the investigation of postpartum exercise to allow for the creation of evidence-based guidelines.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Elon University Protocol 22-112. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The Delphi author group would like to extend their gratitude to all the pilot 46 participants and the following researchers and experts who informed sections of the report 47 relevant to their specialist fields: Dr Celeste Coltman – University of Canberra, Australia; Dr 48 Chris Mills – University of Portsmouth. Thanks, also, to research assistant Katelyn Hickey DPT.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @ritadeeringPhD, @ABSPhysio, @ExercisePreg, @marlizedv, @Drhbomb, @IzzyMoorePhD, @amandaolsondpt
Contributors SMC, RED, GD and EB convened the author group. All authors
conceived the idea for this Delphi study. SMC, RED, SD and MHD performed the
thematic coding and data analysis. SMC and RED wrote the initial draft of the
manuscript. All authors contributed to reviewing and giving feedback on each
iteration of the survey and manuscript drafts. All authors contributed to the literature review. All authors reviewed the final manuscript.
Competing interests IM is an Associate Editor of BJSM.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.